Embedded CMs work with health plan CMs

Collaboration results in better care for patients

Aetna started partnering with physician practices to improve outcomes by coordinating care in 2007 before the term “accountable care” came into use, says Randall Krakauer, MD, national medical director for Aetna Medicare.

The insurer has embedded or dedicated case managers in 75 practices throughout the country where they work with physicians and staff to coordinate care for Medicare Advantage members with chronic illnesses and advanced illnesses. “They are employed by Aetna, but they become indispensible to the physicians and their staff. Our case managers become the physicians’ case managers,” Krakauer says.

Aetna spent a great deal of time and effort over the years into building a robust and effective internal case management program, Krakauer says.

“Case management serves us extremely well. We had impressive results on improving chronic illness and advanced illness, but we wanted to get closer to the scene of action and partner with provider groups to provide case management and do a better job,” he says.

The initiative is working, he says. In 2010, across all participating Medicare Advantage members, the embedded case management program produced a 12% reduction in acute care days, in addition to reductions already achieved by Aetna’s internal case management program, he says.

Aetna’s embedded case managers work in medical groups, including primary care and multi-specialty practices, integrated health systems, and with some independent physicians whose offices are in close proximity to each other.

Each practice chooses an appropriate population to target in the program and develops outcomes metrics that include recommended tests and procedures and chooses how the case managers will operate. The case managers typically work with members by telephone, but some are beginning to see patients face to face at the physician office and visit them at home. “We adapt what we do to the environment of the practice,” he says.

Aetna identifies patients for case management using its health risk assessment and predictive modeling, but many of the members in the program are identified by their physicians. “Providers can identify issues that members may not report on the health risk assessment and they can identify people who need care coordination earlier than when the claims come in. Often the people in the office have a better perception of which patients need interventions than we do by looking at the data,” Krakauer says.

The case managers collaborate with physicians and their staff to determine the needs of targeted patients and to identify barriers to adherence. “Because of the good relationship, physicians can contact the case manager when they are concerned about a patient and ask for follow-up phone calls to make sure the patient has filled his prescription and is following the treatment plan,” he says.

The health plan hires case managers who can build relationships and work largely on their own. They work in the physician practices but report to their supervisors at Aetna.

Aetna’s case managers are predominately nurses, but some are social workers and psychologists with clinical experience.

Some Aetna embedded case managers are already employed by the company; others are hired in the local market. “We screen them carefully, train them in geriatric care and change management, and mentor them. It’s important to have good people who can create a good personal relationship with the medical staff and the patients,” he says.

The case managers meet with the primary care practice team to discuss the needs of patients targeted for the program and identify barriers to adherence.

“We hire people with a real passion for working with people. The key to successful case management is not technology or a script. It is the ability to develop a good personal relationship,” he says.